However, there is one subject close to my heart that keeps hope alive and makes me wonder whether there is some point to it all. Perhaps, before I retire, somebody or bodies somewhere will enable the right circumstances to collide for networks to enable healthcare that delivers better outcomes across organisational boundaries.
I had the privilege of hearing the wisdom of network guru Ewan Ferlie on this subject recently. He starts from the premise that systems can be governed in a number of ways - as hierarchies, markets or networks. I will leave you to decide whether the NHS is a hierarchy or market - it is certainly not a network.
Network power
Historically, networks have been the way professions organise themselves, very helpful if as a professional you see yourself as not having a boss. Building on these informal networks, attempts were made in the late 20th century to manage clinical networks. Our challenge will be to take these to the next stage in their evolution.
Many services will perform better, and enable better outcomes, if organised through networks, which will help to deliver many of the ambitions of health minister Lord Darzi's next stage review. But defining where responsibility, accountability and authority sit will be key to success. Without power, networks cannot provide the solution.
In his research, Ferlie observed that where restructuring, reorganisation and targets got in the way, networks did not fare well. Reconfiguration can place clinicians in competition with colleagues, and when this happens serially it can strain relationships.
Building relationships
Payment by results, as generally used in the NHS, does not sit well with networks either and organisations need to collaborate to ensure it moves beyond a focus on individual organisations and their outputs. However, a well-functioning network team could broker solutions to some of these problems and ensure the system was configured around patient outcomes and pathways, rather than feeding the beast.
Ultimately success - whether in reconfiguring a service or improving outcomes - will depend on relationships. These need to enable trust and mutual respect. Many potential clinical leaders revert to victimhood because hierarchies do not bite for them as they do for managers, and they see the drivers in the system getting in the way. This risks leaving clinicians on the margins and reinforcing the overdone "us and them" - not sensible given the need to improve quality and outcomes.
Hybrid networks
The ambition of the new regulator, the Care Quality Commission, is ultimately to look at integrated care across whole health economies. But there is some way to go in organising the system so as to foster such integration. Surely successful networks, which will have to be managed, are key to this happening. Perhaps we should articulate a vision beyond clinical networks and consider clinical-managerial networks with clinicians and managers working alongside each other.
As we become more sophisticated and as care becomes more complex, extravagant and multi-agency, we need to consider how clinical-managerial hybrid networks can work. In these, some people will carry authority through their roles - for example, by dint of being the chief executive or medical director - and others will carry sapiential authority, by dint of their knowledge. This could be used in the configuration of services such as stroke or trauma, to deal with a chronic disease or to bring together a series of organisations around a common goal - such as an academic health science centre.
The beauty of networks, with their subtle, soft power and focus on dialogue and clinical issues, is that they can hold the key to progress. We have had long enough trying to make transactional systems work - it is time to take a serious look at networks again and bring doctors and managers together around a shared vision.
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